Download PHE Guidelines for the Management of Human Bites

North East and North Central London
Guidance for the Management of Human Bites in
Schools and other Child Care Settings
April 2013
Published: October 2010
For review: February 2014
Acknowledgements: South East London Health Protection Unit
Contents
Page number
Introduction
3
Part 1
3
Background
3
Strategies to prevent adverse outcomes of human bites
3
Part 2
4
Risk
4
Confidentiality
4
Part 3
5
Management in the school or other childcare setting
5
Initial wound care
5
Initial assessment
5
Further assessment
6
Additional actions where a member of staff is involved
6
Further management by healthcare professionals
6
Appendices
7
Appendix A – School action card Hospital A&E departments
8
Appendix B – Procedure to follow in the event of a human
9
bite that breaks the skin
Appendix C – Algorithm for the management of a human
10
bite that does not break the skin
Appendix D – Supporting information
11
Appendix E – Glossary
13
Appendix F - Clinical Care of Severe Bites that Break the
14
Skin
Appendix G – Letter to be taken to A&E or GP – BBV status
not known
16
Appendix H - Letter to be taken to A&E or GP – BBV status
known
17
Appendix I - Suggested Form for recording incident
18
References
Useful contacts/information
21
22
Acknowledgements: South East London Health Protection Unit
2
Introduction
The document is intended as a resource for staff in schools in North East and
North Central London to provide practical guidance for the assessment and
management of infection risks due to human bites in schools and other
childcare settings.
Part 1: Background
It is widely accepted that it is possible, (although extremely rare), for a bite
from an infected individual to transmit hepatitis B, HIV or hepatitis C. In
addition, bacterial infections may occur following human bites and can be
serious if not managed appropriately. Therefore it is essential that bites are
managed promptly. Fortunately, incidents of this nature are extremely rare in
most educational establishments, but as the risk to health can be significant, it
is essential that staff are aware of them and know how to respond. Unlike
occupational exposure in adult healthcare workers, the infection status of the
source is usually unknown and difficult to establish.
Biting that occurs in schools and other child care setting is often an
expression of aggression or frustration in young children. Most human bites in
this situation occur on the fingers or hands. Most do not break the skin.
Strategies to prevent adverse outcomes of human bites
Bites may occur quickly and without an obvious warning to the adults present.
A child may bite when he/she is crowded or cornered and is unable to use
words to get the other child or children to move away. The incidence of biting
tends to increase at times that children find stressful, for example, starting a
new school. Predicting stressful situations and acting to support children
accordingly can decrease the incidence of biting.
The following actions to reduce the infection risk associated with biting may
include the following:
 Take a history from parents to assess the BBV risks in children who
bite repeatedly
 Consider offering testing and possible immunisation against hepatitis B
in children who bite repeatedly
 Consider individual plans for children who repeatedly bite, involving
parents and the child’s GP
 Agree a policy for immunising teachers at risk of hepatitis B
 Consider immunity of classmates at school entry
 Ensure staff wear long sleeved clothing if caring for a child who bites
regularly
Acknowledgements: South East London Health Protection Unit
3
Part 2: Risk
Bites that do not break the skin do not normally pose an infection risk, unless
there is a pre-existing skin break or skin condition. If there is severe bruising
without a skin break however, medical advice should be sought.
Any break in the skin caused by a biting incident is a potential source of
bacterial infection and of bloodborne viruses (BBVs), as it may not be known
whether the biter is infected. However, the risk of transmission from a bite is
extremely low.
To reduce the risk of infection, treatment may be needed for the biter and the
recipient, such as antibiotics, tetanus or hepatitis B immunisation. Following a
biting incident, medical attention and advice must be sought immediately and
risk assessment performed, for both the person bitten and the biter.
Infection risk is from:
 Bacteria including Staphylococcus aureus,
Bacteroides spp and other anaerobes
 Viruses such as hepatitis B, hepatitis C and HIV
Haemophilus
spp
The risk of a BBV being transmitted is higher if there is blood in the biter’s
saliva. The risk may be reduced if the bite is through fabric.
Hepatitis B virus (HBV) infection has the greatest potential for transmission
via this route. HIV transmission has rarely been reported following a bite
injury. Between 1987 and 2006 worldwide there were only four reported cases
of HIV transmission from a bite. In all cases the bite broke the skin and there
was a history of bleeding from the biter’s mouth. Worldwide, there has been at
least two reports of Hepatitis C virus infection being transmitted via a bite;
however there have been no reports of transmission via this route in the UK.
Confidentiality
Staff should be aware that medical information about individual children is
private. Parents should be made aware that there may be circumstances that
personal sensitive information will be shared between the school and health
care professionals.
It is important to keep the number of people who are aware of the person’s
medical conditions to a minimum and divulging such information should be on
a strictly ‘need to know’ basis. The decision as to the extent of any disclosure
within the school will need careful consideration and be minimised in each
case.
Acknowledgements: South East London Health Protection Unit
4
Part 3 Management in the school or other child care setting
Initial Wound Care
If the bite is particularly severe, the biter may require urgent first aid treatment
(e.g. to control the bleeding). In all cases where the bite has broken the skin
the management of the wound should include the following:
Apply first aid:
 Wash and dry your own hands
 Cover any cuts on your own hands and put on disposable gloves
 Encourage the wound to bleed, unless it is bleeding freely. Do not suck
 Wash the wound thoroughly with soap and warm, running water for 1-2
minutes. Do not scrub
 Dry and cover the wound with a waterproof dressing
 Seek medical advice
 If the bite is on the hand the arm should be elevated
 If the biter has blood in the mouth they should swill it out with tap water
Even if the bite has not broken the skin, the area should still be washed
thoroughly with water and soap.
Initial Assessment
All assessments should include the possibility that the person bitten and the
biter both may have been exposed to a BBV or bacterial infection. All bites
should be examined to ascertain whether the skin has been broken and the
following information recorded for all incidents where this is the case:













An accident/incident report should be completed
Who was bitten
Who was the biter
When and where did the incident take place
Who was also present
Factors that may have contributed to the occurrence of the incident
Examine the mouth of the biter to assess the likelihood that the bitten
person was exposed to the biter’s blood
Examine and describe the wound of the person bitten to include
whether there is a possibility of soil contamination
Any known immunosupression (problems with the immune system) in
the biter or person bitten
Any known allergies to medicines
Any known infections or other medical conditions in both parties
Whether the person bitten is up to date with their tetanus vaccinations
Has the biter or recipient been immunised against Hepatitis B
Acknowledgements: South East London Health Protection Unit
5
Further assessment
If the biter or the person bitten is known to have or is considered likely to have
a BBV infection then refer immediately to the local A&E department,
telephoning the department beforehand to alert them. Telephone the parents
and inform them of the incident and ask them to accompany the child to A&E.
Ideally arrangements should be made for the biter to have a blood test for
BBVs as this will help to inform management of the person bitten.
If the biter or bitten person is not thought likely to be infected with BBV, but
the wound is severe it may be appropriate to refer to the local accident and
emergency department. Otherwise local primary care facilities may be used.
If a part of the body has been torn off, for example part of an ear, it should be
surrounded by ice, stored in a plastic bag for transport to hospital.
Additional optional questions which should be asked if the school lead/first
aider feels it appropriate include:
 Are any of the parents of the biter or bitten person known to be infected
with hepatitis B, hepatitis C or HIV?
 Are any of the parents of the biter or bitten person known to be
intravenous drug users?
 Has the biter or bitten person or anyone in their families been ill with
jaundice?
 Were the biter or bitten person, or their parents born in an area where
BBVs are endemic (Africa, Asia, South America)
Additional actions where a member of staff is involved
The organisation should ensure that:
o An accident/incident report is completed
o The appropriate line manager is informed
o If the bite breaks the skin the occupational health department should
be informed
Those whose work puts them at increased risk of biting should be offered
hepatitis B vaccination where appropriate. They should be made aware of the
immediate action to take following a bite.
Further Management by Health Professionals
This will include:





An assessment of the need for antibiotics to prevent bacterial infection
Assessment of the need for immunisation against tetanus and hepatitis B
Assessment of the need for HIV PEP (drugs to prevent HIV infection in
situations where the biter is HIV positive or highly likely to be HIV positive)
Taking a sample of blood from the bitten person to store and possibly test
later.
Taking a sample of blood from the biter to test for existing infection
Acknowledgements: South East London Health Protection Unit
6
APPENDICES
Acknowledgements: South East London Health Protection Unit
7
Appendix A
School action card
Information required following a human bite
The following information should be recorded:
 Who was bitten
 Who was the biter
 When and where did the incident take place
 Who was also present
 Factors that may have contributed to the occurrence of the incident
 Examine the mouth of the biter to assess the likelihood that the
bitten person was exposed to the biter’s blood
 Examine and describe the wound of the person bitten to determine
the possibility of soil contamination
 Any known immunosupression (problems with the immune system)
 Any known allergies to medicines
 Any known infections or other medical conditions in both parties
 Whether the child who is bitten is up to date with their tetanus
vaccinations
 Has either child been immunised against hepatitis B
Date:
Hospital A&E departments
Hospital
Telephone number
Queen’s Hospital
King George Hospital
0845 130 4204 or 01708 435 0000
020 8983 8000
Whipps Cross Hospital
The Royal London Hospital
St. Bartholomew’s Hospital
Newham General Hospital
Homerton University Hospital
Barnet Hospital
Chase Farm Hospital
Edgware Community Hospital
North Middlesex University Hospital
Royal Free Hospital
University College Hospitals
Whittington Hospital
020 8539 5522
020 7377 7000
020 7377 7000
020 7476 4000
020 8510 5555
0845 111 4000
0845 111 4000
020 8952 2381
020 8887 2000
020 7794 0500
0845 155 5000
020 7272 3070
North East & North Central London
Health Protection Team, 2nd Floor.
151 Buckingham Palace Road.
London. SW1W 9SZ
020 7811 7100
Acknowledgements: South East London Health Protection Unit
8
Appendix B
Procedure to follow in the event of a human bite wound that
breaks the skin.
Use normal first aid procedure plus use of disposable gloves
At school
Encourage bleeding from skin
wound, do not suck wound
At school
If there is blood in the mouth of
the biter swill it out with water
At school
Wash the wound with soap
and running water
At school
Cover the wound
(Plaster or dressing)
At school
Phone nearest A&E department and explain
incident and action taken so far and seek advice on
next steps. Depending on risk assessment getting
to A&E within 1 hour may be needed.
Ensure ongoing support for the bitten person and
biter as appropriate
o
At school
Notify
 H&S and Occupational health
teams
 Complete accident/incident
report
 RIDDOR (Reporting of injuries,
diseases and dangerous
occurrences regulations 1995)
At the Hospital
Clinical assessment of risk of
infection and tissue damage
At the Hospital
Antibiotics may be prescribed to prevent bacterial infections
Possible actions for viral infections:
 If Consultant decides there is a risk of HIV
infection, they will begin anti-HIV-therapy for 1
month (this is very rare)
 Vaccination history will be taken for Hepatitis B.
Either an accelerated course or a booster may be
given
 If there are concerns around hepatitis C, regular
testing will take place and treatment against
hepatitis C will begin if infected
 Follow up – GP and Occupational health
Hospital A&E departments Barking &
Dagenham, Redbridge, Havering, Waltham
Forest, Newham, Tower Hamlets, Hackney:
Hospital A&E departments Barnet, Camden,
Enfield, Haringey, Islington:
Queen’s Hospital – 0845 130 4204
King George Hospital – 020 8983 8000
Whipps Cross Hospital – 020 8539 5522
The Royal London Hospital – 020 7377 7000
St. Bartholomew’s Hospital – 020 7377 7000
Newham General Hospital – 020 7476 4000
Homerton University Hospital – 020 8510 5555
Barnet Hospital – 0845 111 4000
Chase Farm Hospital – 0845 111 4000
Edgware Community Hospital – 020 8952 2381
North Middlesex University Hospital –020 8887 2000
Royal Free Hospital – 020 7794 0500
University College Hospitals – 0845 155 5000
Whittington Hospital – 020 7272 3070
Acknowledgements: South East London Health Protection Unit
9
Appendix C
Algorithm for the Management of a human bite that does not
break the skin
Has the bite made an opening in the
skin?
No


Yes – see
Appendix B
Clean the area and
reassure the child
Letter to parents of biter
and/or recipient
Acknowledgements: South East London Health Protection Unit
10
Appendix D
Supporting Information
Bacterial infection from human bites
A multi-centre study of bites in adults and children in the United States
reported that 54% of the patients were hospitalised (Talan et al, 2003). The
median number of isolates per wound culture was four (three aerobes and
one anaerobe); aerobes and anaerobes were isolated from 54% of wounds,
aerobes alone were isolated from 44%, and anaerobes alone were isolated
from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus
aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%),
and Prevotella melaninogenica (22%). Candida species were found in 8%.
HIV Transmission from Human Bites
The risk of HIV transmission through biting is thought to be very low but is
more likely if there is extensive tissue damage and if there is bleeding in the
mouth of the biter.
Although there have been some case reports of HIV transmission as a result
of human bites (Rickman and Rickman, 1993; Andrea et al, 2004; QuavaJones et al, 2005; Didmar et al, 2006), this is extremely rare. HIV is present
in saliva at low concentrations but the presence of blood in the mouth of the
biter is likely to increase the risk of transmission. The risks of HIV
seroconversion from needlestick injury are 0.3-0.5%. Since needlestick
injuries transmit 20 times more HIV-infected cells than a human bite from a
HIV positive individual the HIV transmission risk from biting is likely to much
lower (Rickman and Rickman, 1993).
Of the documented cases of HIV transmission from a human bite two involve
HIV positive patients who inadvertently bit during a grand mal seizure, in both
cases, blood was noticed in the mouth of the patients at the time of the bite
(Barra et al, 2004; Vidmar et al, 1996). Another case report documents HIV
transmission by an HIV positive parent with dental caries and bleeding gums
who bit his daughter (Quava-Jones et al, 2005). The Centers for Disease
Control in the United States report no cases of occupational transmission of
HIV by a human bite (CDC, 2005)
Hepatitis Transmission from Human Bites
The Centers for Disease Control, Atlanta (1989) report that saliva of some
persons infected with HBV contains HBV-DNA at concentrations 1/1,000 to
1/10,000 of that found in the infected person's serum. HbsAg-positive saliva
has been shown to be infectious when injected into experimental animals and
in human bite exposures. However, HBsAg-positive saliva has not been
shown to be infectious when applied to oral mucous membranes in
experimental primate studies or through contamination of musical instruments
or cardiopulmonary resuscitation dummies used by HBV carriers.
Acknowledgements: South East London Health Protection Unit
11
Hepatitis C appears to be more easily transmitted than HIV but there is
currently no PEP or vaccine. Hepatitis C RNA has been found in saliva and
there are at least two case reports of transmission via human bites
(Henderson, 2003).
Acknowledgements: South East London Health Protection Unit
12
Appendix E
Glossary
Allergy
An inappropriate and harmful response of the immune system to a normally harmless
substance
Bacteria
Small single-celled organisms that cause disease
Bloodborne virus (BBV)
This refers to viruses which can be spread through blood: hepatitis B, hepatitis C and
HIV (Human Immunodeficiency Virus).
Infection
The multiplication of an infectious agent in the body of an infected person or animal
Immunoglobulin
Antibodies which can be used to temporarily increase person’s immunity to an
infection.
Immunisation
The use of a vaccine to produce an immune response to a particular disease in an
individual
Immunosuppression
A weakened immune system (caused by various means), making a person more
susceptible to infections.
Immunity/immune
Protection against infection achieved either by vaccination, or by natural infection
Intact skin
If the bite has not punctured the skin, there is no risk of infection either from bacteria
or blood borne viruses. The incident should be managed by cleaning the area and
reassuring the patient.
Post Exposure Prophylaxis (PEP)
Treatment for example drugs, to reduce risk of infection following possible exposure
Punctured skin
If the bite has punctured the skin then there is a theoretical risk of transmission of
infection.
Transmission
The way in which an infectious agent is spread
Vaccine
A preparation administered as a precaution against contracting a disease. Usually
the vaccine stimulates the body to produce antibodies to the disease, making the
person immune.
Acknowledgements: South East London Health Protection Unit
13
Appendix F
Clinical Care of Severe Bites that Break the Skin
The hospital doctor or GP assessment will include the following (this is to
serve as a guide only. Local policies to be followed):
Full clinical assessment to examine for signs of infection, foreign bodies,
damage to blood vessels, nerves, tendons, joints, bones and
lymphadenopathy (e.g. swelling at site).
Antibiotic prophylaxis
Bacterial infection of severe human bite wounds is common. A seven day
course of Co-amoxiclav is recommended as first line treatment. In persons
allergic to penicillin, metronidazole plus either erythromycin or doxycylcine are
alternatives.
Tetanus prophylaxis
For those whose immunisation schedule is not up to date or whose status is
unknown then the risk of tetanus infection associated with the bite should be
assessed. Tetanus is only a risk if the bite is deep and there is possible
contamination with soil. In this case manage according to the Department of
Health Green Book recommendations. (See references)
Bloodborne viruses
A risk assessment should be made and where appropriate hepatitis B
vaccine/immunoglobulin and or HIV post exposure prophylaxis (PEP) should
be offered.
HIV PEP is unlikely to be required unless the biter or victim is known to be
HIV positive or is considered highly likely to be HIV positive. Even then it
should only be provided with specialist support. There are no current
guidelines on the use of PEP in children.
Hepatitis B prevention must be considered according
immunisation history and hepatitis B status or risk factors
to
previous
Hepatitis C appears to be more easily transmitted than HIV but there is
currently no PEP or vaccine. However, if the child who bites or is bitten is
known to be hepatitis C positive then the other child, (or member of staff), will
require serial testing and appropriate referral.
The Children’s HIV association (CHIVA) has developed PEP Guidelines for
children and adolescents exposed to blood-borne viruses. (See references)
Acknowledgements: South East London Health Protection Unit
14
If the risk is considered significant then the person exposed should be tested
as follows (From HPA Inoculation Injuries and Children in schools and similar settings: Risk
assessment guidelines for Health Protection Units, November 2009 )
Time after
exposure
Hepatitis B
Hepatitis C
HIV
RNA testing
Antibody testing
Baseline
Storage
6 weeks
Yes
Yes
12 weeks
Yes
Yes
Yes
Yes
24 weeks
Yes
Yes
(Yes)
*If HIV PEP was taken the follow up tests should be 12 weeks after stopping PEP
Acknowledgements: South East London Health Protection Unit
15
Appendix G
Letter to be taken to A&E or GP – BBV status not known
This person has sustained a human bite which has broken the skin. The
bloodborne virus status of the biter and bitten person is not known.
Please manage according to your own local policy and in line with
recommendations on management of human bites and involving potential
exposure to blood borne viruses please consider the following






Need for antibiotic prophylaxis or treatment
Need for tetanus immunisation
Need for hepatitis B immunisation
Need for HIV PEP
Serum for storage
Ensure clear arrangements are in place for follow up, including repeat
blood samples at appropriate intervals and completion of hepatitis B
vaccine course if required.
Yours sincerely,
Health Protection Team
Acknowledgements: South East London Health Protection Unit
16
Appendix H
Letter to be taken to A&E or GP – BBV status known
This person has sustained a human bite which has broken the skin.
The <<biter / bitten person>> is known to be
<< HIV / Hepatitis B / Hepatitis C>> positive. (Delete as appropriate)
Please manage according to your own local policy and in line with
recommendations on management of human bites and involving potential
exposure to blood borne viruses please consider the following






Need for antibiotic prophylaxis or treatment
Need for tetanus immunisation
Need for hepatitis B immunisation
Need for HIV PEP
Serum for storage
Ensure clear arrangements are in place for follow up, including repeat
blood samples at appropriate intervals and completion of hepatitis B
vaccine course if required.
Yours sincerely,
Health Protection Team
Acknowledgements: South East London Health Protection Unit
17
Appendix I
Suggested Form for recording incident
Section A: Details of the Recipient
First Name:
Surname:
Date of Birth:
Job title / Post
Home address:
Home telephone number:
GP:
GP address and telephone number:
Hepatitis B Status
Has recipient been immunised against Hepatitis B virus? Yes
No
N/K
If Yes:
Date of completion of course?
Date of last vaccination booster?
Was antibody test done?
Result:
Immune / Partially immune / Non responder
Section B: details of Source
Is the source patient known?
If Yes:
First Name:
Yes
No
Surname:
Date of Birth:
Address:
Home telephone number:
Mobile telephone number:
GP:
GP address and telephone number:
Acknowledgements: South East London Health Protection Unit
18
Section C: Assessment of exposure risk
1 Nature of the incident:
Date of incident:
Time of incident:
Place of incident:
Name and contact details of witness:
Nature of material:
Significant:
Yes
No
Significant:
Yes
No
Overall, is the exposure significant?
Yes
No
Nature of injury:
2. Assessment of source infectivity (tick appropriate section)
Virus type
Known Positive
Known negative
Unknown risk
or known high
or known low risk
risk
Hepatitis B
Hepatitis C
HIV
Section D: Investigations checklist
Done
Has first aid treatment been given?
Blood taken from recipient, test requested for antiHBs (if
appropriate) and serum storage?
Request for bloods to be taken from source patient (with
informed consent) and tests requested as necessary?
Acknowledgements: South East London Health Protection Unit
19
Section E: Post exposure prophylaxis treatment record
Has HBIG been given?
Yes / No
Has hepatitis B vaccination been given?
Yes / No
Has HIV PEP been offered?
Yes / No
Has HIV PEP been accepted?
Yes / No
Has written consent been obtained?
Yes / No
Has HIV PEP been given?
Yes / No
Time between exposure and receiving PEP:
Drugs prescribed for PEP:
Section F: details of follow-up arrangements
To include:
Follow up arrangements for receiving test results and continuing vaccinations;
Precautions advised during follow up period;
Any precautions who have given advice and the advice given;
The action taken to prevent recurrence;
Compliance with medication prescribed;
Potential adverse effects of drugs;
Results of any follow-up testing.
Acknowledgements: South East London Health Protection Unit
20
References
Andrea S., Barra L., Costta L., Sucupira M., Souza I and Diaz R. HIV Type1
Transmission by Human Bite. AIDS Research and Human Retrovirus, 2004;
20: 349-350
CDC, 2005 www.cdc.gov/mmwr/PDF/rr/rr5409.pdf (Accessed 20 October 2010)
CHIVA, 2009 www.chiva.org.uk/health/guidelines/pep-ref (Accessed 20 October
2010)
Department of Health. (2006) Immunisation against infectious disease.
Department of Health. London (Green Book)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_079917 (Accessed 20 October 2010)
Hamilton J. Larke B., Qizilbash A. Transmission of hepatitis B by a human
bite: an occupational hazard. Canadian Medical Association Journal, 1976;
115: 439-440
Health Protection Agency, (2009) Inoculation Injuries and Children in Schools
and similar settings: Risk assessment Guidelines for Health Protection Units
http://www.hpa.org.uk
Henderson D. Managing occupational risks for Hepatitis C in the Health Care
Setting. Clinical Microbiology Reviews, 2003, 16:543-568
Pretty I., Anderson G., Sweet D. American Journal of Forensic Pathology,
1999; 20: 232-9
Quava-Jones A., Bartholomew M, Bartholomew C. Human Bites. A risk
factor for HIV transmission. IAS Conf HIV Pathology Treat 2005 July 24-27;
3rd: Abstract No MePo10.1P10
Rickman K., Rickman L. The potential for transmission of human
immunodeficiency virus through human bites. Journal of Acquired Immune
Deficiency Syndrome 1993; 6:402-6
Stockheim, J., Wilkinson N., Ramos-Bonoan, C., Human Bites and Blood
Exposures in New York City Schools. Clinical Pediatrics, 2005; 44:699-703
Talan DA; Abrahamian FM; Moran GJ; Citron DM; Tan JO; Goldstein EJ;
Clin Infect Dis. 2003; 37(11):1481-9
Vidmar L., Tomazic J., Poljak M., Seme K., Kristancic L., Klavs I., Maticic M.
A human bite: possible mode of HIV-1 transmission
Int Conf AIDS 1996 July 7-12; 11: 362 (abstract no Tu.C.2563)
Acknowledgements: South East London Health Protection Unit
21
Useful contact/information
North East and North Central London Health Protection Team
2nd Floor
151 Buckingham Palace Road
London SW1W 9SZ
020 7811 7100
[email protected]
Health Protection Agency
http://www.hpa.org.uk
Acknowledgements: South East London Health Protection Unit
22